W20 Symptoms in the Pharmacy: ENT

Question 1

What are some common Ear, Nose and Throat conditions?

Answer 1

*Sore throat
*Oral thrush
*Ear wax
*Otitis externa and otitis media (ear infection)
*Glue ear
*Motion sickness
*Allergic rhinitis
*Sinusitis

Question 2

Sore throat- questions to ask:

Answer 2

Antibiotics make no difference to majority of bacterial sore throats

*Age: children of school age more likely to have streptococcal infection, young children more likely to develop croup
*Duration: usually resolves within a week, longer than this may warrant referral
*Severity: if extremely painful after 24-48h, especially when other symptoms of a cold are absent, will warrant referral
*Associated symptoms: cough and cold, aches and pains expected, but difficulty swallowing and hoarseness may be signs of more serious condition
*Current medication: especially inhaled steroids, carbimazole and
immunosuppresants

Question 3

Sore throat-Things to exclude

Answer 3

*Laryngitis (sore throat and diminished voice) in babies and young children may lead to croup (difficulty breathing and stridor)
*Long-standing hoarseness (> 3 weeks, esp. without other symptoms)may also be a sign of laryngeal cancer
*Glandular fever (caused by Epstein-Barre virus) presents with severe sore throat and dysphagia, swollen lymph glands, malaise, fever, creamy exudate on tonsils
*Oral thrush (see later)

Question 4

OTC Treatment for sore throats: (2)

Answer 4

*Simple analgesia, e.g. paracetamol, ibuprofen, aspirin (>16 only)
*Anti-inflammatory, anesthetic and antiseptic lozenges and sprays (Difflam spray)
(also, see mouth ulcers)
e.g. Stepsils, Halls soothers, Strefen

Question 5

Sore throat:
When is an Urgent referral required?
(including to A&E if very unwell):

Answer 5

• respiratory distress
• drooling
• systemically very unwell
• unable to swallow
• difficulty opening mouth
• muffled voice – or making a high pitched sound as they breathe (stridor)
• dehydrated or unable to take fluids
• signs of being systemically unwell and at risk of immunosuppression.

Question 6

Baby symptoms of oral thrush: (2)

Answer 6

Do not want to feed, nappy rash

Question 7

Older children and adults symptoms of oral thrush: (5)

Answer 7

• cracks at corners of mouth (angular cheilitis)
• not tasting things properly
• unpleasant taste in mouth
• pain/soreness
• difficulty eating and drinking

Question 8

Treatment of Oral thrush :

Answer 8

*Antifungal, miconazole
e.g. Daktarin
*Applied qds in adults and children >6years,
bd for younger
*Interacts with a number of other medicines,
including warfarin and statins

Question 9

When to refer oral thrush to GP:

Answer 9

*Babies under 4 months
*Older children and adults without an obvious cause
*Recurrent or persistent infection
*Failed medication
*Patients taking an interacting medicine that can’t be stopped, e.g.
warfarin

Question 10

Ear wax features:

Answer 10

*Normal physiological substance (cerumen)
*Is antibacterial and cleans, lubricates and protects ear canal
*Excessive build-up of hardened wax can affect some people

Question 11

Symptoms of excessive ear wax:

Answer 11

• sensation of blockage
• temporary deafness
• discomfort (not pain)
• tinnitus (ringing sound)
• rarely, dizziness/nausea

Question 12

What is the treatment of excess ear wax:
What not to use:

Answer 12

*Olive oil, almond oil (not if pt allergic) or sodium bicarbonate drops
recommended
* warm drops at room temperature before use
* a few drops into the ear with affected ear uppermost, staying like this for a few
minutes after use
* use qds for 3-5 days

Do NOT use earbuds to try to remove wax

Question 13

What is Otitis externa (OE)?
What are the symptoms? (3)

Answer 13

*Inflammation and infection of skin in the ear canal
*1 in 10 people affected at some point in life
*May be localised (e.g. a boil) or diffuse
*Symptoms:
* Localised – severe pain
* Diffuse – pain, itching, hearing loss, discharge
*Suspected OE should be referred

Question 14

What is Otitis media (OM)?

Answer 14

Infection of the middle ear compartment
* Middle ear normally airtight other than via Eustacian tube into back of throat
* Viral cold can block tube and lead to fluid build-up in middle ear (may be secondarily infected with bacteria)
* Best treatment is with analgesia
* Antibiotics do little even if bacterial infection
* Refer if: under 2 yrs, no resolution in a few days, systemically unwell, discharge from ear

Question 15

What is Glue ear?

Answer 15

*Also known as “serious otitis media”
*OM that persists or is recurrent
*Can be bilateral
*Can cause deafness, which in turn affects language development
*Often spontaneously resolves
*Sometimes requires operation to remove fluid

Question 16

What are the symptoms of motion sickness?

Answer 16

• Nausea
• +/-
• Vomiting
• Pallor
• Cold sweats
• Hypersalivation

Question 17

What are the avoidance measures for motion sickness?

Answer 17

*Elevated seating position
*Look at horizon
*Fresh air
*Keep cool
*Breaks
*Avoid stimuli
*Distractions

Question 18

What are the Non- pharmacological treatments for motion sickness? (2)

Answer 18

Ginger (tablet, biscuit or tea)
Acupressure bands

Question 19

What are the pharmacological treatments for Motion sickness? (4)

Answer 19

1. Hyoscine hydrobromide
   * From age 3 OTC (BNFc says age 4 for motion sickness)
   * Antimuscarinic adverse effects
   * Short-acting (up to 4 hours)
2. Scopoderm patches
   *Over 10 years
   *Apply 5-6 hours before journey (or night before)
   *Lasts for up to 3 days, so remove when journey finished
   *Adverse effects may last for 24 hours after removal
3. Cinnarizine
   * Min. age 5 years
   * Intermediate acting – up to 8hours
4. Promethazine
   * Min. age 2 years
   * Long-acting – more than 8 hours

Question 20

What is allergic rhinitis:
What are the symptoms? (2)
Who suffers from it?

Answer 20

• General term
• Defines nasal inflammation in response to histamine

*Rhinorrhoea/nasal congestion/nasal itching/sneezing
*Eye symptoms

• children and young adults
  May develop asthma
  Patient may have suffered before

Question 21

Non-pharmacological treatment of allergic rhinitis:

Answer 21

*When the pollen count is high the person should:
* Avoid pollen by closing windows, wearing wraparound sunglasses and avoiding grassy areas particularly during early morning, evening and night
* Avoid drying clothes outside
* Apply Vaseline around their nostrils to trap the pollen
* Shower and wash their hair after being outdoors to remove pollen
* Vacuum regularly and dust with a damp cloth

Question 22

Pharmacological treatment of allergic rhinitis:

Answer 22

*Stepped approach:
* For people with occasional symptoms of allergic conjunctivitis, children aged 2–5 years and people who prefer an oral formulation treat with an oral antihistamine.
* If the predominant symptom is sneezing or nasal discharge treat with an oral antihistamine.
e.g. piriton, chlorphenamine, piriteze, loratadine

For people with more persistent symptoms, and predominant symptom is nasal blockage, treat with an intranasal corticosteroid (people over 18 years
[OTC]) e.g. Beconase nasal spray for hayfever relief and Pirinase nasal spray
(Beclometasone diproprionate and fluticasone proprionate)

Question 23

Pharmacological treatment of allergic conjunctivitis:

Answer 23

Signs of allergic conjunctivitis - sodium cromoglicate eye drops may provide additional relief.

Question 24

• Ms S comes to the pharmacy asking for something for her 6 year old son.
• He has had red, runny eyes for a week. He has also been sneezing and has a runny nose.
• His symptoms seem to be worse in the morning and evening.
• What further questions would you like to ask?
• What condition do you suspect?
• Which treatments would be suitable for this pt?
• Which symptoms might make you refer a patient with this condition?
• Ms S mentions that she has similar, but somewhat milder symptoms.
  She has suffered from the same condition in the past, but not for a few years. She is 6 months pregnant. What can you recommended for Mrs S?

Answer 24

-Any allergies, medications, family history, systemic symptoms, new pets, do symptoms improve when it rains, eye symptoms- nature of discharge, bilateral/unilateral, how did it start, history of this or allergies previously?
-Hay fever, Allergic rhinitis
- The fact that the symptoms are worse morning and evening points to allergic rhinitis
Oral antihistamines:
- Loratadine, cetirizine hydrochloride, piriton
Eye drops:

Non pharmacological advice: Stay away from pollen, hoover/clean house

Refer: If symptoms don’t go after treated/ 2-3 weeks

Ms S: Saline nasal spray, eye drops

Question 25

• Mr W and his 10-year-old son, Sam, are due to travel on a long flight, lasting 16 hours. Sam has suffered from travel sickness since he was 2 years old and has in the past taken promethazine. However, Mr W has been refused the sale of promethazine at another pharmacy and now consults you asking to buy it.
• You don’t have promethazine in stock and so are asked to suggest an alternative.
• Why might a sale of promethazine have been refused?
• What other questions would you ask?
• What alternative product would you suggest?
• What counselling advice would you give (use PIL of chosen product)?

Answer 25

Caution= Epilepsy
Any other symptoms, other meds, other medical conditions, is promethazine usually effective? does it cause any adverse effects? Preference for a particular formulation?

Hyoscine hydrobromide, cinnarizine

Question 26

Symptoms to refer allergic rhinitis:

Answer 26

• Wheezing/SOB
• Pregnant/Breastfeeding
• Ear pain
• Facial pain
• Person is pregnant or breastfeeding
• Uncontrolled symptoms continue after 2–4 weeks despite correct use of medication
• Urgent resolution of severe symptoms affecting quality of life is required
• Person is a child under 2 years requiring treatment
• There is nasal blockage in the absence of rhinorrhoea, nasal itch and sneezing
• There is unilateral nasal discharge, especially in a young child, to check for a trapped foreign body

Question 27

Non- pharmacological treatments for motion sickness:

Answer 27

Ginger (tablet, biscuit or tea)
Acupressure bands